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Chapter 1: Promoting Professionalism: An Overview for Medical Educators

Chapter Authors: Nancy D. Spector, MD & R. Franklin Trimm, MD

Professionalism is an essential element of being a good pediatrician. This has been confirmed by the Association of American Medical Colleges (AAMC) for medical students, by the Accreditation Council for Graduate Medical Education (ACGME) for residents and fellows, and by the American Academy of Pediatrics (AAP) and the American Board of Pediatrics (ABP).

There are many definitions of professionalism. For our purposes, we will use Stern’s definition as highlighted in his book Measuring Medical Professionalism: “Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”1 This definition emphasizes the fact that professionalism is a behavior that can be observed. Another important concept that is relevant to medical students, residents and fellows is professional identity formation described as “the moral and professional development of students, the integration of their individual maturation with growth in clinical competency, and their ability to stay true to their values which are both personal and core values of the profession.”2 Encouraging trainees to embrace both their personal principles and values as well as the core values of the profession facilitates their ability to navigate the inevitable conflicts that arise in the practice of medicine.3

Purpose of this Guide

Each year, program directors are asked by the ABP to determine whether each resident or fellow in their program has met expectations in the area of professional conduct. In addition, the program director must certify that the trainee has achieved competence in professionalism at the end of training in order to be eligible to take the certifying examination.

This guide was created initially through a joint effort of the Program Directors Committee of the ABP and the APPD in order to help program directors answer three questions:

  1. What are the important elements of professionalism?
  2. How can expectations regarding professionalism be communicated to pediatric residents?
  3. What methods are appropriate for assessing professionalism during residency training?

This version was updated by the Education and Training Committee of the ABP that includes member representatives from the Council of Medical Student Education in Pediatrics (COMSEP), Association of Pediatric Program Directors (APPD), and the Council of Pediatric Subspecialties (CoPS) and has been expanded to address the needs of the continuum of learners from students, residents, and fellows into continuous professional development. This guide is now presented in an online, electronic format to allow users to take advantage of certain features built into its design such as:

  1. being able to search by individual Competencies for linked content throughout the guide; and
  2. adapting specific content (e.g., Reflective Exercises or Short Cases) to use for a variety of types of educational sessions.

Figure 1It also reflects the maturation of competency-based assessment as we begin to move towards entrustment decisions that are fundamental to the assessment of entrustable professional activities (EPAs).  Figure 1 (as depicted by Burke, Carraccio, and Englander) illustrates the interactive continuum of EPAs with Domains of Competence, Competencies, and Milestones. To clarify terms in this Figure, Domains of Competence are the six original ACGME Competencies, examples of Competencies are illustrated by the chapters of this guide. The language related to competency-based education and training has evolved and we intend to continue to update this guide to remain contemporary and relevant.  The pediatric competencies and their associated milestones referred to throughout this Guide include the full set included in the Pediatric Milestone Document, incorporating a number of additional areas not part of the subset reported biannually to the ACGME by residency and fellowship directors.

Three new chapters were added to the guide to focus on issues of increasing relevance to professionalism:

  1. Electronic Professionalism – the far reaching effects of social media and the professionalism issues that cross into modern communications via this medium demand a stand-alone chapter
  2. Humanism within Pediatrics – the emphasis on humanism as the heart of medicine requires special attention
  3. Trustworthiness:  A Foundation of Professionalism – this new chapter helps establish links between Milestones and Entrustable Professional Activities and, in doing so, highlights the developmental nature of professionalism and the importance of professional identity formation. Conceptualizing professionalism as a maturational process may help us mitigate some of the challenges that come with assessment.

This guide lays out the dimensions of professionalism in pediatrics and provides suggested methods for teaching and assessing professionalism among pediatric trainees. Chapters 2-8 outline aspects of professionalism as seen from different perspectives. In developing this guide, we have attempted to follow the model described by Stern: “setting expectations, providing experiences, and evaluating outcomes.”4

Setting Expectations

Setting expectations about professionalism begins at the institutional level – it must be part of the core values and part of the culture in which trainees work. Numerous publications address elements of professionalism and how they should be taught and assessed. Perhaps the most important document that can be used to set expectations is Medical Professionalism in the New Millennium: A Physician Charter, initially published in 2002 and hereafter referred to as the Physician Charter.5 This document outlines three fundamental principles and ten professional responsibilities.  It can be viewed here.

The three fundamental principles are:

  1. Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
  2. Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
  3. Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

The ten professional responsibilities are:

  1. Commitment to professional competence
  2. Commitment to honesty with patients
  3. Commitment to patient confidentiality
  4. Commitment to maintaining appropriate relations with patients
  5. Commitment to improving quality of care
  6. Commitment to improving access to care
  7. Commitment to a just distribution of finite resources
  8. Commitment to scientific knowledge
  9. Commitment to maintaining trust by managing conflicts of interest
  10. Commitment to professional responsibilities

These responsibilities are incorporated into the subsequent chapters of this guide. Each chapter then provides specific examples of behaviors that exemplify professional conduct and those that demonstrate lapses in professionalism. We have adapted many of these behavioral statements from The Royal College of Paediatrics and Child Health document, Good Medical Practice in Paediatrics and Child Health: Duties and Responsibilities of Paediatricians.6

Providing Experiences

Medical students, residents and fellows confront situations that challenge their professionalism on a daily basis, but they may need assistance to recognize the nuances of professionalism. Most faculty members consistently exhibit professional behaviors in their care of patients, but faculty development efforts may be required to highlight the varied components of professionalism.

In this guide, we provide a number of suggestions for ways to teach professionalism. Formal opportunities for learning may occur in community-based rotations, in international rotations, during teaching rounds on the inpatient service, or with a skilled, experienced outpatient clinician. Other formal learning can take place in conferences, some of which may focus explicitly on professionalism issues (like those outlined in this guide) and others that may incorporate aspects of professionalism, such as a mortality and morbidity conference. Each chapter has a series of vignettes, reflective exercises, and short cases that can be used in a conference or small group setting to stimulate discussion about professionalism. These individual teaching strategies can be accessed in each chapter or by searching by competency online. Program directors are encouraged to modify the cases to make them more applicable to a local setting. In addition, it is our hope that educators will build on the educational materials in this guide to develop innovative strategies to create and implement curricula and assess the impact of the curricula on learners.

One important consideration: educational opportunities must allow time for reflection. Faculty and trainees need to gain additional experience in observing and reflecting on their own and others’ behavior. Trainees should be encouraged to share their stories during all teaching sessions. Although this is true for all aspects of learning, it is particularly crucial for advancing professionalism within a residency or fellowship program.

Evaluating Outcomes

Medical educators need to be able to document that students, residents and fellows are achieving competency in professionalism. Assessment measures ought to be valid and reliable. Fortunately, there are an increasing number of tools that can be used to assess professionalism. The use of critical incidents, peer assessment, patient assessment, and multisource feedback instruments (separately or combined into a portfolio) have enhanced the ability to assess professionalism. In the final chapter of this guide, we discuss several of the more promising assessment methods and provide suggestions on the best ways to implement these in a training program. The goal should be to include many perspectives on professional conduct in the assessment. As with all competency-based assessments, evaluations collected by multiple evaluators over time will provide a more complete appraisal of an individual. As valid and reliable tools are developed through research around assessment of competencies, milestones and entrustable professional activities, we will need to adapt accordingly in order to provide the most meaningful assessment of professionalism.

Implementing a Professionalism Curriculum

Our hope is that medical educators will use this guide to help create and reinforce the culture of professionalism within medical student and GME programs. It may be helpful to set explicit expectations regarding professional conduct early in training, using the topics covered in this guide. Some clerkship and program directors have used the orientation period to begin discussing professionalism and assist students, residents and fellows in developing their own “code of conduct.” As the year progresses, discussions of issues such as teamwork, documentation practices (e. g., procedure logs, completing evaluations, patient charting, logging duty hours), and morbidity and mortality conferences can highlight professional behavior. Each of the chapters in this guide could also be used as a foundation for a short educational session or incorporated into a longitudinal curriculum focusing on humanism and professionalism and wellness.

Beyond formal teaching about professionalism, it is clear that much of what is learned during medical training comes from the “hidden” curriculum, which Hafferty defines as the lessons that come from the structure, process, and content of the educational experience itself, including the organizational culture of the institution.7 Professionalism is taught in the middle of the night or in a passing interaction between hospital staff members. The culture of the institution and department can significantly influence professional behavior. Thus, it is critical for program directors to devote as much attention to the hidden curriculum as they do to shaping the formal curriculum.

Along the way, medical educators are likely to detect lapses in the professional conduct of trainees. “Lapse” is the preferred term for most professionalism issues for several reasons. First, it is generally recognized that professionalism is a characteristic of a behavior, not of the individual. Second, lapses in professional behavior occur in a context and often arise as a result of a conflict between two competing values.6 When lapses are identified, the appropriate faculty member or program director should bring these to the trainee’s attention. After discussion of the event, the trainee should be given a clear description of the behavior in question and expectations for future professional conduct. This discussion should be documented. The trainee should leave the discussion with the understanding that repeated lapses in professional conduct will be considered unacceptable. Further guidance for addressing serious professionalism problems is provided in Chapters 9 and 10 (Chapter 10 coming soon).

Most students, residents and fellows come to their training with a general understanding of professional conduct, but they are unlikely to have been challenged with the stresses and competing priorities they will face during medical school, residency and fellowship. This guide acknowledges that professionalism, like many other aspects of training, is a developmental process and is context specific. We are challenged to do more than simply identify egregious behavior. Rather, we must promote professionalism through role modeling, setting explicit expectations, identifying professionalism lapses, implementing remediation plans and reinforcing behaviors that distinguish professional conduct in all aspects of work and life.

Professionalism must be incorporated in all aspects of our work as pediatricians. Demonstrating that we are competent in this essential domain is required during training, must be documented at the time of board certification, and is assessed as part of the ongoing maintenance of certification. We hope this guide will be a useful resource for medical educators and trainees who are role modeling, teaching and assessing professionalism.

References

  1. Stern DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006.
  2. Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional Formation: Extending Medicine’s Lineage of Service into the Next Century. Academic Medicine 2010; 85: 310-317.
  3. Holden M, Buck E, Clark M, Szauter K, Trumble J.  Professional Identify Formation in Medical Education:  The Convergence of Multiple Domains.
  4. Stern DT, Papadakis MA. The Developing Physician: Becoming a Professional. New England Journal of Medicine 2006; 355: 1794-1799.
  5. ABIM Foundation. American Board of Internal Medicine, ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Annals of Internal Medicine 2002; 136: 243-246.
  6. Good Medical Practice in Paediatrics and Child Health: Duties and Responsibilities of Paediatricians. Royal College of Paediatrics and Child Health, 2002. (accessed at http://www.rcpch.ac.uk/doc.aspx?id_Resource=1744.)
  7. Hafferty FW, Franks R. The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education. Academic Medicine 1994; 69: 861-871.

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